Vestibular Dizziness

Vestibular dizziness refers to vertigo and imbalance from disease of the labyrinth, vestibular nerve or central vestibular pathways. Peripheral causes are the commonest, but central causes, chiefly posterior circulation stroke, must be identified because they are dangerous.

• Peripheral causes: vestibular neuritis, labyrinthitis, Meniere disease, benign positional vertigo, perilymph fistula, ototoxicity.
• Central causes: brainstem or cerebellar stroke, haemorrhage, demyelination, vestibular migraine, tumour, vertebrobasilar insufficiency.

Illusion of rotation or movement, with nausea, vomiting, oscillopsia and gait unsteadiness.

• Peripheral: acute onset, severe, unidirectional horizontal nystagmus that suppresses with fixation and beats away from the lesion, positive head impulse test, able to walk with support.
• Central: gaze evoked or direction changing nystagmus, vertical or torsional nystagmus, negative head impulse test, skew deviation, severe truncal ataxia, new headache, dysarthria, diplopia.
• Associated hearing loss and tinnitus suggest labyrinthine or cochlear involvement.
• Differential diagnosis: posterior circulation stroke, vestibular migraine, orthostatic hypotension, arrhythmia, anaemia, hypoglycaemia, medication effect, anxiety, multiple sclerosis, acoustic neuroma.
• Complications: falls and injury, chronic dizziness, anxiety, persistent postural perceptual dizziness, permanent unilateral vestibular loss, stroke if missed.

Clinical, using the HINTS examination (head impulse, nystagmus, test of skew) in continuous acute vestibular syndrome.

• Blood pressure lying and standing, glucose, ECG, otoscopy, hearing assessment (Rinne, Weber, audiometry).
• Dix Hallpike test for episodic positional vertigo.
• MRI with diffusion weighted imaging if central signs, vascular risk factors, or abnormal HINTS; CT misses most posterior fossa infarcts.
• Pure tone audiometry for suspected Meniere disease.

Control symptoms briefly, exclude stroke and begin early vestibular rehabilitation.

• Supportive: bed rest limited to 1 to 2 days, hydration, fall prevention, early mobilisation, vestibular exercises (gaze stabilisation, balance and habituation) from day 2 to 3.
• Pharmacological: prochlorperazine 5 mg orally three times daily or 12.5 mg IM once, or cinnarizine 15 to 30 mg three times daily, or promethazine 25 mg at night; limit vestibular suppressants to 3 days as they delay compensation. Vestibular neuritis within 72 hours: prednisolone 1 mg/kg daily (maximum 60 mg) for 5 days then taper over 10 days. Meniere disease: betahistine 16 mg three times daily, low salt diet under 2 g sodium daily, thiazide diuretic where indicated. Vestibular migraine prophylaxis: propranolol 40 to 80 mg twice daily or amitriptyline 10 to 50 mg at night.
• Procedures: intratympanic dexamethasone or gentamicin for refractory Meniere disease; surgery for perilymph fistula or acoustic neuroma.
• Special groups: pregnancy, avoid betahistine and cinnarizine unless essential, use prochlorperazine briefly; elderly, avoid prolonged sedatives and give fall precautions; children, vestibular migraine is common.
• Red flags: abnormal HINTS, new severe headache, neck pain after trauma, inability to sit or walk, diplopia, dysarthria, facial numbness, sudden unilateral deafness, vascular risk factors.
• Follow-up: review at 1 to 2 weeks; refer to vestibular rehabilitation if symptoms last more than 3 weeks; audiology and ENT for hearing loss.